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The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
1
Antimicrobial Resistance:An OverviewDr. Elaine Larson
Columbia University School of Nursing
Hosted by Paul [email protected]
www.webbertraining.com
Microbes/Humans
– Microbes: 5 X 1031
(50,000,0000,000,000,0000,000,0000,000,000)
– Humans: 6 X 109
(6,000,000,000)
– Microbiology in the 21st century, ASM, 2004
Without 02 Boiling water Ice
Rocks
Microbial Adaptability (Blaser)
Crushing Pressure& No Sun
Us
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
2
Bad Bugs!! (Blaser)
Secular trends of approximate prevalence rates for penicillinase-producing, methicillin-susceptible strains of Staphylococcus aureus inhospitals (closed symbols) and the community (open symbols), UnitedStates
The scientific problem being addressed
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
3
Methicillin (oxacillin)-resistantStaphylococcus aureus
Vancomycin-resistantenterococci
Non-Intensive Care Unit PatientsIntensive Care Unit Patients
Antimicrobial Resistance amongPathogens Causing Hospital Infections
Source: National Nosocomial Infections Surveillance (NNIS) System
MRSA–related hospitalization rates, US, 1999–2005Klein, et al. Emerg Infec Dis 2007; 13:1840-6
3rd generation cephalosporin-resistant Klebsiella pneumoniae
Fluoroquinolone-resistantPseudomonas aeruginosa
Non-Intensive Care Unit PatientsIntensive Care Unit Patients
Antimicrobial Resistance amongPathogens Causing Hospital Infections
Source: National Nosocomial Infections Surveillance (NNIS) System
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
4
New β-lactamases Reported Per Year(responsible for resistance to penicillins,
cephalosporins, carbepenems, etc)
Jacoby GA, β-Lactamase Nomenclature, Antimicrob Agents Chemother 2006; 50:1123-9.
Trimethoprim/sulfamethoxazole (TMP/SMX)Resistance Among Bacterial Patient-Isolates*
San Francisco General HospitalMartin JN, et al: J Infect Dis 1999;180:1809-18
* 30,886 patient-isolatesStaphylococcusaureusEscherichia coliEnterobacter spp.KlebsiellapneumoniaeMorganella spp.Proteus spp.Serratia spp.Citrobacter spp.%
Res
ista
nt P
atie
nt-Is
olat
es
Non-HIV unitsHIV unitsPrevalence of TMP/SMX useamong AIDS patients
Notifications of methicillin-resistant Staphylococcus aureus(MRSA) in Western Australia, 1983–2002, community-acquired(WAMRSA) versus epidemic (EMRSA) strains
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
5
Prevalence of Antimicrobial-Resistant (R)Pathogens Causing Hospital-Onset
Intensive Care Unit Infections: 5 years
Organism %Increase*Fluoroquinolone-R Pseudomonas spp. 2657 49%3rd generation cephalosporin-R E. coli 1551 48%Methicillin-R Staphylococcus aureus 2546 40%Vancomycin-R enterococci 4744 40%Imipenem-R Pseudomonas spp. 1839 20%
* Percent increase in proportion of pathogens resistant to indicated antimicrobialSource: National Nosocomial Infections Surveillance (NNIS) System
Total Approved Antibacterials: US
Spellberg, et. al., CID May 1 2004, Modified
Drug-resistant pathogens are agrowing threat
• Each year ~2 million patients get an infection in UShospitals, about 90,000 of these die
• More than 70% of bacteria causing hospital-associated infections are resistant to ≥1 drug mostcommonly used to treat them
• Persons infected with drug-resistant organisms aremore likely to have longer hospital stays and requiretreatment with less effective, more toxic, and/ormore expensive drugs
http://www.cdc.gov/drugresistance/healthcare/problem.htm
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
6
Resistance Expanding in theCommunity: S. aureus
• 25-30% of healthy people are colonized withStaphylococcus aureus
• Generally this poses little risk, considered‘normal flora’
• In past 5 years, there are increasing cases,outbreaks and deaths among healthypersons with a new community strain ofantibiotic-resistant S. aureus
The Human Face of MRSA: Carlos
• 1/07 Carlos Don, 12years old, returned froma school trip with flulikesymptoms. Startedantibiotics, hospitalizedon a ventilator, died
The Human Face of MRSA: Simon
• Healthy Simon, aged14 months, motherwith doctorate inpublic health, diedwithin 24 hrs ofMRSA sepsis
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
7
The Human Face of MRSA: Brandon
• Washington Redskinsdefensive tackle BrandonNoble after knee surgery.“This infection has had ahuge impact on my life andwill continue to impact meand my family in the nearfuture. Hopefully, I am not acarrier and will not have toworry about this forever. ”
The Human Face of MRSA: Bryce
• A healthy 14-month old whocontracted MRSAand spent weeksICU. Survived.
• Medical bills todate: ~$1 million
One Typical Day: 11/12/07• Chicago Tribune: Superbugs Spur FDA, Drug Firms To Action• Associated Press: Staph Germ Undermines Body's Defenses• LA Times:'Superbug's' Killer Cousin; An Antibiotic-Resistant Staph Strain• TriCities.com (TN):Staph Infections Aren't New• The Courier News (IL):Staph Myth Debugged• Wash Post:FDA Approves Products That Reduce Spread Of Dangerous
Bacteria• Wash Post:Are Antimicrobial Soaps Breeding Tougher Bugs?• Rochester Democrat and Chronicle (NY):MRSA Increase Is Warning To Use
Antibiotics Wisely• Business Wire: Tommy G. Thompson Speaks Out Against Misinformation
Regarding MRSA ``Superbug''• The Columbus Dispatch (OH):Deadly Threat; Infections Are Reminder That
Antibiotics Need Protection• Chicago Tribune:Garlic vs. 'Superbug‘• Akron Beacon Journal (OH): Officials Seek To End Staph Misinformation• Associated Press: Gregoire Asks Dept Of Health To Convene MRSA Panel• US Fed News: Sen. Brown Introduces Strategies To Address Antimicrobial
Resistance Act• States News Service: With Lethal MRSA Infection Continuing To Pop Up In
Schools Across NYS, Schumer Bill Will Provide Tax Credit For Research AndDevelopment Of Products To Combat Infectious Diseases
• Tallahassee Democrat (FL): Know The Facts About MRSA Infections
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
8
Many ‘faces’ of MRSA
Epidemiology of the Transmissionof Antibiotic-Resistant Bacteria
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
9
Antibiotics in Agriculture• Antimicrobials are routinely added to animal feed
and water to promote animal growth– Rationale is to promote more rapid growth
reducing farming expenses– Mechanisms are debated although most
commonly invoked is the reduction of infections,especially in unsanitary conditions
• Many of the antibiotics used in this setting are of thesame class as those used to treat human infections– Macrolides, tetracyclines, glycopeptides
Percentage U.S. swine receivingantibiotics in their feed (2005-6)
US DOA, 2007 cited in NY Times, 12/16/07
Chronology/History:1940s-50s
• 1940: Pathologist Florey discovers killingproperties of penicillin, which was firstwidely available antibiotic and used in WWIIfor soldiers
• 1943: Drug companies mass produced• 1958: Nobel Prize for discovery of bacteria’s
ability to exchange genetic material
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
10
Chronology/History:1960s
• Fast-developing resistance, but large numberof new antibiotics enter market
• 1960: Methicillin introduced• 1961: MRSA turns up in UK hospital• 1963: MRSA appears in Denmark• 1967: Penicillin-resistant streptococcal
pneumonia in New Guinea
Chronology/History:1970s-80s
• Antibiotics routinely prescribed for viralinfections (e.g. colds), strong antibioticsused for transplants, cancer
• 1977: Strep pneumonia bacterium resistantto every available drug (S.Afr)
• 1983: 18 people hospitalized for Ab-resistantsalmonella from beef fed Abs
• 1986: Sweden bans Abs for animal food
Chronology/History:1990s
• Drug firms reduce Ab R&D• 1992: Ab-resistant infections kill 13,000
hospital patients• 1998: Denmark taxes Abs used as animal
growth promoters. EU bans use of humanAbs for animals feed
• 1999: US Fed Interagency Task Force on AMResistance launched
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
11
Chronology/History:2000s
• 2000: Congressional Act to take strongsteps to reduce resistance is notfunded. Public health efforts lag
• 2001: Anthrax scare results instockpiling cipro
• 2003: Drug resistant Acinetobacterinfection Iraqi War soldiers, leading tomany amputations
Inappropriate use?
Chronology/History:2000s
• 2005: France bans 12 sore-throatmedications containing antibiotics
• 2006: EU bans using any antibiotic topromote animal growth
• US STILL has made minimal similar efforts
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
12
Chronology/History: 2007• Cases of MDR-TB quadruple in S. Afr• WHO launches plan to fight MDR-TB• Avian flu virus is evolving to be resistant to
current vaccine strains• 10 times as many cases of MRSA in hospitals
than previously thought• FDA still considering approval for a new Ab
for cows that could increase resistance inAbs used in humans
• CQ Researcher 2007; 17:683
MDR-TB
• Kills ~2 million worldwide annually• MDR-TB has doubled in past few years
in many countries (WHO)• Summer 2007: Andrew Speaker:
Healthy US newlywed on honeymoonhad MDR-TB. Where did he get it?
• Only 30-50% of those with extensivelyresistant strains recover
• Now we have XDR (extensively resistant) TB
(Music courtesy of R. Weinstein)
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
13
S. aureus
Penicillin
[1950s]Penicillin-resistant
S. aureus
Evolution of Drug Resistance in S. aureus
Methicillin
[1970s]Methicillin-resistantS. aureus (MRSA)
Vancomycin-resistantenterococci (VRE)
Vancomycin
[1990s]
[1997]
Vancomycinintermediate-
resistantS. aureus (VISA)
[ 2002 ]Vancomycin-
resistantS. aureus
Attributable Costs of Resistance
• MRSA (vs MSSA)– Bacteremia1
• Median hospital stay increased by 2 days• Median hospital charges increased $6916
– Surgical site infection2
• Median hospital stay increased by 5 days• Median hospital charges increased $13,901
1. Cosgrove SE et al. Infect Control Hosp Epidemiol 2003
2. Engemann JJ et al. Clin Infect Dis 2003
FOR MORE INFO...
MRSA Prevalence Survey:NYS Prisons
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
14
1012 Drug felony
6580 Violent felony
2117.5 Prior jail term
7.56.5 No prior conviction
3717 No prior arrest
3821Average length ofincarceration (months)
2711 White
2231 Hispanic
5055 African American
Ethnic status (%)7921741Number of inmates
BedfordHills
SingSing
Results: Feb-May 2006• S. aureus positive
• MRSA
• SCCmec type IV
• PVL + MSSA
• PVL + MRSA
• 25.5 (124/487)
• 10.5 (13/124)
• 100 (13/13)
• 21.6 (24/111)
• 61.5 (8/13)
Staphylococcus aureus Reports LabA: April – October 2005 Manhattan
• MSSA 58% (446)• MRSA 35% (270)
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
15
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
16
Summary: CA-MRSA cases differsignificantly from NYC population
• Predominantly male• White, non-Hispanic• Higher proportion 24-64 y-o• Affluent• Highly educated• Concentrated in Manhattan
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
17
“At the beginning of the 21stcentury, antimicrobial resistance
is common, has developed againstevery class of antimicrobial drug,and appears to be spreading into
new niches.”
http://www.cdc.gov/ncidod/EID/vol11no06/05-0167.htm
Proportion of resistance to ≥3 antimicrobial agentsamong isolates of E. coli in Nigeria
International Spread of ResistantClones of Pneumococcus
Dowson, Trends Microbiol
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
18
Resistant N. gonorrhoeae
Resistant Acinetobacter Infections:Military
http://www.cdc.gov/ncidod/EID/vol11no08/05-0103-G.htm
Antibiotic Resistance Genes in Multidrug-Resistant Acinetobacter sp. Isolates from
Patients Treated at the Walter Reed
Sixteen unique resistance genes and fourmobile genetic elements detected in 75unique patient isolates
89% resistant to at least 3 antibiotic classes;15% resistant to all antibiotics tested
Eight major clonal types, very complex geneticbackground
Hujer et al, Antimicrob Agents Chemother 2006; 50:4114-23.
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
19
PubMed Citations for Antibiotic ResistantAcinetobacter, 1987-2006
Global Spread of DistinctGenetic Hospital Strain of VRE
http://www.cdc.gov/ncidod/EID/vol11no06/04-1204-G4.htm
Mechanisms of Resistance• Emergence, which occurs because of
microbial evolution• Dissemination of resistant organisms
– at the microbial level (e.g. clonal spread,plasmids, transposons)
– at the population level (e.g. hospital orcommunity spread)
Courvalin P. Emerg Infec Dishttp://www.cdc.gov/ncidod/EID/vol11no10/05-1014.htm
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
20
Characteristics that EnhanceResistance
• Speed. Bacterial populations candouble ~ every 20 mins
• Exchangeability. Bacteria canexchange genetic material
• Mutation. Under antibiotic pressure,resistant mutants emerge
Some species areintrinsically more resistant
SporesCapsules
Three Fundamental Mechanisms
• Enzymatic degradation of antibacterial drugs• Alteration of bacterial proteins that are
antimicrobial targets, and• Changes in membrane permeability to
antibiotics.
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
21
Transfer of Resistance
Mutation (no transfer required)
Transformation
Transduction
Conjugation
How does natural selection work?
VariationInheritanceSelectionTimeAdaptation
From “Battling bacterial evolution: The work of Carl Bergstrom”Understanding Evolution, University of California.
How does natural selection work?
VariationInheritanceSelectionTimeAdaptation
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
22
How does natural selection work?
VariationInheritanceSelectionTimeAdaptation
Antibiotic resistance can beeither plasmid mediated ormaintained on the bacterial
chromosome
Discussion• Determine at least 2-3 actions that
could be taken to reduce resistance by– The public– The healthcare community– The government
• Develop a plan of action for making thishappen
• Describe how you would evaluate theeffectiveness of this plan
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
23
Avoiding Resistance:What the Public Can Do
• Careful hygiene, particularly in moist, busyenvironments such as gyms
• Don’t share towels, clothes• Avoid antibacterial soaps with triclosan;
consider using alcohol rubs• Don’t demand Abs for viral infections• Don’t save or take anybody else’s Abs• Find out about hospital infection rates
Public Knowledge/Attitudes• 453 Wash Heights households interviewed
(2,386 people)• 88% thought colds were caused by bacteria• Only 29.8% agreed that most colds and flu
would improve without medication• 89.9% stated that antibiotics are usually or
sometimes needed to treat viral throatinfections
• 27.6% stated that Abs were usually orsometimes indicated for asthma attacks.
Antibiotics without Prescription
• Availability of antibioticswithout prescription in NewYork City
• 42nd Annual Meeting of theInfectious Diseases Societyof America (IDSA), Boston,10/04.
Larson & Figueroa, J Urban Health2004; 81:498-504
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
24
Survey of all independent pharmacies,grocery stores, delicatessens, bodegasand botanical or health food stores in 30blocks of the major commercial areas ofthree neighborhoods were surveyed:
Predominantly Hispanic neighborhood(Washington Heights)Predominantly Black neighborhood(Central Harlem)Predominantly Caucasian neighborhood(Upper West Side)
Methods
Procedure
• A trained surveyor of sameethnicity as the neighborhoodresidents entered each storeand ascertained whetherantibiotics were available onthe shelf or upon request tothe store attendant.
Results• 101 stores were surveyed
• No antibiotics were available inthe predominantly Black orCaucasian neighborhoods
• In 7/34 (20.6%) of stores in theHispanic neighborhood,antibiotics were available on theshelves, and were also availableupon request in all other stores
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
25
What Types?• Antibiotics offered
included ampicillin,amoxicillin, tetracycline,erythromycin
• Antibiotics were offeredas single dosesindividually wrapped andin larger quantities.
Educational Materials: Hands
Clinician Prescribing Patterns:Community
• Rates of prescribing antibiotics for viral URIrange from 25-56%
• When presented with clinical scenarios ofviral pharyngitis, 81% of 948 clinicianrespondents used an inappropriate treatmentstrategy
• 22% of 1,363 ED visitors reported that theirphysician routinely prescribed Abs for a cold
• >800 physicians rated the issue of resistanceas the lowest of seven determinants of theirchoice regarding antibiotic prescribing
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
26
Nurse Practitioners (NP)• Survey of 149 (48%) educational programs• 45.3% reported <4 hours of lecture on
antimicrobial therapy, but 51.9% did not offera microbiology course (Sym, et.al. J Am Acad NursePract 2007; 19:477-485).
• National NP guidelines do not includecompetencies regarding antimicrobialresistance and/or proper antibioticprescribing
• NPs misuse and overuse antimicrobialagents in a similar fashion to physicians.
Avoiding Resistance: WhatHealthcare Systems Can Do
• Control antibiotic use• Prevent cross-transmission between
patients and from healthcare worker topatient– Appropriate barrier techniques (cohorting,
isolation)– Appropriate hygiene, particularly hands
• Identify and act on infections rapidly
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
27
Current Status in Hospitals
• 34/1000 patients have active HA-MRSAinfections and 12/1000 additional arecolonized
• About 1.2 million patients infectedannually
• Resistance increasing similarly in otherorganisms
Antimicrobial drug use: 130 U.S. Hospitals
• 59.8% of patients received one of 50antibacterial agents(1,074,174/1,795,504)
• 776/1000 patient days• 792 doses/100 patient days
Polk et al. CID 2007; 44:664-70
CDC’s Key Prevention Strategies
OptimizeUse
PreventTransmission
PreventInfection
EffectiveDiagnosis& Treatment
Antimicrobial-Resistant Pathogen
AntimicrobialResistance
Antimicrobial Use
Infection
Susceptible Pathogen
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
28
12 Steps to Prevent AntimicrobialResistance Among Hospitalized Children
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Potential Barriers to Adherenceto GuidelinesKnowledge
Lack of awareness – No knowledge of CDC 12 Steps
Lack of familiarity – Unfamiliar with 12 Steps in generalor with specific component(s)
Potential Barriers to Adherenceto GuidelinesAttitude
Lack of agreement – Disagreement with CDC 12 steps orwith specific component(s)
Lack of self efficacy - Perceived lack of confidence orlack of preparation to perform specific guideline(s)
Lack of outcome expectancy – Lack of belief thatguideline(s) will lead to an important patientoutcome
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
29
Potential Barriers to Adherenceto GuidelinesPractice
Frequency (Adherence) - How often guideline(s) arefollowed
External factors - Lack of time, support staff,administrative support, and/or financialreimbursement
Cabana MD, et al. Why Don’t Physicians Follow Clinical PracticeGuidelines? A Framework for improvement. JAMA 1999;282:1458-1465
Survey
– Neonatology fellows and facultyattending a conference “Infection andImmunity in the Preterm Infant” at the70th Annual Perinatal DevelopmentSymposium on June 1, 2007
• Used with permission from Patel S, Saiman L. ColumbiaUniversity Department of Pediatrics.
KnowledgeLack of Awareness
• Awareness of 12 Step Campaign– 59% not aware of the campaign– 25% somewhat aware– 16% very aware
– 28% received educational materials• (including 4 unaware of 12 Steps)
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
30
Outbreak of Multidrug-Resistant Acinetobacterin the US Military Health Care System
Associated with Military Operations in Iraq
• Evaluated 3 potential sources: patient skin,soil, healthcare environment
• Prevalence– Skin: 1/160 patients (0.6%)– Soil: 1/49 samples (2%)– Environment: 7/7 hospitals (100%)
• Environmental contamination played a majorrole
Scott et al, Clin Infect Dis 2007; 44:1577–84
How Often Do Asymptomatic HealthcareWorkers Cause Methicillin-Resistant
Staphylococcus aureusOutbreaks? A Systematic Evaluation
Distribution of MRSA outbreaks with a strong epidemiologicalassociation with healthcare workers.
Vonberg et al, Infect Control Hosp Epidemiol 2006; 27:1123-7.
Fighting Resistance in Hospitals(Zillich, Infect Contr Hosp Epidemiol 2006; 27:1088)
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
31
Proven Control Measures
– “Barrier precautions”• Gowns• Gloves• Hand hygiene• Control of solid waste
disposal
• Admissionculturing forMRSA?
Avoiding Resistance:What Can Government Do?
• Good surveillance: National AntibioticResistance Monitoring System (NARMS) isrun on a shoestring
• Stricter tabs and regulations regarding Abuse in humans and animals
• Private sector has been unwilling on its own• Better support of development of new Abs• Funds for social marketing campaigns
IDSA recommendations• “Wild-card patent extension.”• A company could extend the market exclusivity period of
another FDA-approved drug as long as the company commitsto invest a portion of the profits derived during the extensionperiod back into antibiotic R&D.
• Restoration of all patent time lost during FDA's review ofpriority antibiotics
• Extended market exclusivity similar to what has beensuccessfully implemented for pediatric and orphan drugs
• Other potential statutory incentives:• Tax incentives for R&D of priority antibiotics Measured liability
protections• Additional statutory flexibility at FDA regarding approval of
antibiotics, as needed• Antitrust exemptions for certain company communications• A guaranteed market
http://www.idsociety.org/temp.aspx?RefURL=http%3a%2f%2fold.idsociety.org%3a80%2fTemplate.cfm%3fSection%3dAntimicrobials%26Template%3d%2fContentManagement%2fContentDisplay.cfm%26ContentID%3d9770
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
32
STARR Act• On 9/27/07, Reps. Jim Matheson (D-UT),
Michael Ferguson (R-NJ) and other membersof Congress introduced the Strategies toAddress Antimicrobial Resistance (STAAR)Act, H.R. 3697. The STAAR Act providesnecessary and critical solutions to preventand control the spread of antimicrobial-resistant "bad bugs."
• http://www.idsociety.org/STAARAct.htm
Enacted 4Emerging/Existing 21Targeted 3Watch code 3TOTAL 31
State Laws Requiring Outcome Measurement
Will It Work?
• In European countries (e.g.Netherlands, Denmark) where hospitalstringent policies regarding are inplace, rates of MDRO have droppedprecipitously
• No mechanism in US to mandate suchpolicies; must be done on an individualsystem or institution basis.
The Global Problem of Antimicrobial ResistanceDr. Elaine Larson, Columbia University School of Nursing
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
33
Thanks to…
• M. Blaser, F. Lowy, R. Weinstein, M.Marx, A. Ratner, S. Patel from whomslides were obtained with permission
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